L.M. 52 y.o. female Maureen Donah 2013 Sodexo Southcoast Dietetic Intern.
-
Upload
dwain-chase -
Category
Documents
-
view
218 -
download
2
Transcript of L.M. 52 y.o. female Maureen Donah 2013 Sodexo Southcoast Dietetic Intern.
Past Medical HistoryCOPD Type 2 Diabetes HyperlipidemiaObesityFibromyalgiaHx of recent UTIs Kidney StonesIrritable Bowel Syndrome Depression
L.M. was admitted 1/8/13Caucasian5’0” 212# (stated) BMI 41.4Social Hx: patient doesn’t drink
alcohol and used to smoke in the past
140
4.3
99
27
16
1.1186
Emergency RoomIn the ER L.M. presented
with left-sided flank painCAT scan showed UPJ
stone with hydronephrosis and diverticulitis
Hydronephrosis is the swelling of the kidney due to a back up of urine. http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm
Procedure 1/9/13Pre-op dx: ?colovesical fistula (due
to air in the bladder) and left proximal ureteral stone◦Cystoscopy ◦Fistulogram◦Left retrograde pyelography◦Left ureteral stent placement
Post-op dx: Left proximal ureteral stone and colovesical fistula confirmed
The Plan The pt was treated with IV
antibiotics, IV fluids, and IV narcotics
1/11/13 pt started clear liq diet and tolerated well and was adv to a DM diet
Pain was off and on and was better controlled with p.o. medications
1/12/13 pt was d/c home
The Plan
The pt was told to follow up with primary doctor within 5-7 days
Follow up with GI for colonoscopy after antibiotic is finished
Follow up with surgery in 2-3 weeks
Re-admitted 1/25/13Left flank painDiarrhea and vomiting PTA
139
4.3
101
27
11
1.0189
Started DM 1800cal dt 1/26/13-2/1/13 with fair to poor intake
RD Assessment 2/4/135’0” 212# (Stated) BMI 41.4Adj. body wt: 128#/58kg
Kcals 1450-1750 (25-30 kcals/kg)Protein 69-76g (1.2-1.3g/kg)Fluid 1750mL (30mL/kg)
On full/clears since 2/1/13 with fair intake
Prep for surgery
2/5/13 SurgeryDx: Sigmoid diverticulitis with
colovesical fistulaLaparotomy with sigmoid colon
resection and repair of colovesical fistula
Nutrition after Fistula RepairNPO 2/5-2/8Started clear liquid 2/9-2/10
◦Not tolerating clears, episodes of vomiting
NPO 2/11-2/13
Nutrition after Ileostomy Nutritional Needs (58kg)
◦Kcals 1450-1750 (25-30kcals/kg) ◦Protein 75-87g (1.3-1.5g/kg)◦Fluid 1750mL (30mL/kg)
IVF D5 ½ NS + 20mEq KClDiet advance to clear liquids 2/13Diet advance 2/14 to diabetic diet for
breakfast onlyL.M. not tolerating, vomiting
continues
The PlanPatient not tolerating liquids at allIn 2 weeks L.M. had 2 surgeries
and was NPO for 7 days and received 7 days of liquid trays
With this minimal nutrition the plan was to start TPN - Central line 2/15/13
Pt at refeeding risk! ◦Potassium 3.7◦Magnesium ?◦Phosphorous ?
Nutrition Support (TPN) 2/15Day 1 custom bag 1,000mL/day
50g AA, 100g dextrose, no lipids due to shortage
IVF (D5 ½ NS) kept at 100mL/hr will decrease by day 2 per PA
Day 2 TPN 2/16/132,000mL/day 80g AA, 175g
dextrose, no lipids, 20 units insulin
IVF switched to Normal SalineIVF decreased to a combined rate
with TPN to 100mL/hr
◦Potassium 3.1◦Magnesium 1.7◦Phosphorous 1.9
Day 3 TPN 2/17/13TPN at goal: 1,800mL/day 85g AA,
160g dextrose, 25 units insulinIVF (NS) at combined rate of
100cc/hr To provide 884 kcals/day Only meeting 55% of calorie needs
◦Potassium 3.1◦Magnesium ?◦Phosphorous 1.6
Day 4 TPN 2/18/131,800mL/day 85g AA, 160g
dextrose, no lipids, 35 units insulin
◦Potassium 3.2◦Magnesium 2.3◦Phosphorous 2.3
◦Pt now not passing gas and has hypoactive bowel sounds
2/18/13Vomited KUB showed multiple dilated
small bowel loops, consistent with a small bowel obstruction.
Started NGT to LWS 1500cc output
Day 5 TPN 2/19/131,800mL/day 85g AA, 160g
dextrose, 50g lipids, 45 units insulin
To provide 1334kcals, meeting ~83% of calorie needs
NGT to LWS 2550cc output
◦Potassium 3.3◦Magnesium 2.3◦Phosphorous ?
Day 6 TPN 2/20/131,800mL/day 85g AA, 160g
dextrose, no lipids, 55 units insulin
NGT to LWS output
◦Potassium 3.3◦Magnesium 2.2◦Phosphorous 4.3
3000cc 3000c
*Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale) BMI 37.5 Down 19.5# since admission
Gastric Secretions
Production and composition of gastric secretions varies. Daily estimates ~1-3L
~1liter saliva and ~2 liters gastric secretions: ~3 liters total
The electrolyte composition of each liter is estimated at 20-100mEq sodium, 50-160mEq chloride, and 5-15mEq potassium
Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18.
Gastric Secretions
Date 2/18 2/19 2/20
NGT output 1500cc 2550cc 3000cc
Chloride 92 (L) 92 (L) 93 (L)
Bicarbonate 34 36 (H) 37 (H)
* No blood gas labs taken
pH PCO2 HCO3- Differential
Metabolic Acidosis
Normal or decreasing
Diabetes, renal failure,
increased acid
production
Metabolic Alkalosis
Normal or increasing
Vomiting, increased
NGT output, administrati
on of alkaline solutions
RespiratoryAcidosis
Normal or increasing
Obstruction, pneumonia, mediastinal
disease
Respiratory Alkalosis
Normal or decreasing
Anemia, CHF,
exuberant mechanical ventilation
Day 7 TPN 2/21/131,800mL/day 85g AA, 160g
dextrose, 50g lipids, 60 units insulin
NGT to LWS 1500cc output Started to pass flatus but still
hypoactive bowel soundsKUB still seeing multiple dilated
loops
Day 8 TPN 2/22/131,800mL/day 85g AA, 160g
dextrose, no lipids, 60 units insulin
Started clear liquid diet NGT clamped for 3hrs then LWS
for 1hr NGT to LWS 2250cc output Pt was given MOM (30mL) q2h
while awake
TPN ContinuesPt continued on clear liquid diet
and TPN, with fair PO intakeSBO resolving 2/25/13 per KUBDiet advanced to full liquid on
2/27/13 with good intakeLunch on 2/28/13 diet advanced
to soft easy to chew and TPN d/c’d
Cleared for DischargePt was tolerating soft diet with
fair intake and supplements. Pt was discharged home with
VNA on 3/2/13Pt was told to follow up with
surgery for barium enema as an outpatient and eventually reverse her ileostomy
Re-admitted on 3/6/13Abdominal pain and minimal
output from ileostomy. Low sodium of 122 on admission Hyponatremia resolved after
hydrationElectrolytes were stable and she
was tolerating a full diet. D/c’d home 3/12/13
Re-admitted 3/20/12Fatigue, nausea, and abdominal
painFound to have another low
sodium on admission of 129 Pt was hydrated and stableD/c’d home on 3/22/13Still follow up with surgery
regarding ileostomy
Re-admitted 3/25/13Nausea, vomiting, and abdominal
painPt vomiting and unable to keep
any food or fluids downPt was again found to be
dehydrated Sodium on admission 132Pt was given fluids and tolerated
diet D/c’d 3/31/13 to nursing home
facility
ReferencesJohnson ML. Gastric Secretions:
Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18.
Medline Plus. Hydronephrosis. (2013).
http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm